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Upon completion of this exercise, participants should be able to:
A 50-year-old female (AW) was admitted to hospital for a radical hysterectomy to treat cervical cancer. A crossmatch for 2 units of RBC was ordered.
Based on these results:
Pretransfusion testing results (recollected specimen)
Whenever an ABO group on a current specimen does not agree with the patient's historical blood group, there are several possibilities, including:
In this case the results on the recollected specimen determined that patient misidentification had occurred on this admission and that the initial specimen was not from patient AW.
A protocol was initiated to supply uncrossmatched group O Rh negative RBC for urgent transfusions to patients without historical records whose samples had been drawn by the same blood collector implicated in AW's initial specimen.
The blood collector (SH) who had drawn the first specimen had completed her shift and was off duty. She was immediately contacted at home and questioned about the collection procedure for the patient in question.
After much discussion SH said that she used computer-generated patient identification labels and admitted to pre-labelling specimen tubes for two patients on her last collection trip of the day because she was in a rush to finish her shift. She insisted that she had checked patient arm bands for all collections as that was her normal procedure.
See the case discussion, including interactive questions with feedback.
This quiz is offered as a self assessment.
Callum, JL, Kaplan, HS, Merkley, L L, Pinkerton, PH, Rabin Fastman, B, Romans, RA. Reporting of near-miss events for transfusion medicine: improving transfusion safety. Transfusion 2001; 41: 1204-11. [ Medline ]
Contreras M, de Silva M. Preventing incompatible transfusions. Br Med J 1994; 308(6938): 1180-1. [ full text ]
Linden JV, Wagner K, Voytovich AE, Sheehan J. Transfusion errors in New York State: an analysis of 10 years' experience. Transfusion 2000;40(10):1207-13. [ Medline ]
Lumadue, JA, JS Boyd, and PM Ness. Adherence to a strict specimen-labeling policy decreases the incidence of erroneous blood grouping of blood bank specimens. Transfusion. 1997;37:116972. [ Medline ]
McClelland DBL, Phillips P. Errors in blood transfusion in Britain: survey of hospital haematology departments. Br Med J 1994;308:1205-6. [Full Text]
Mercuriali F, Inghilleri G, Colotti MT, Fare M, Biffi E, Vinci A, Podico M, Scalamogna R. Bedside transfusion errors: analysis of 2 years' use of a system to monitor and prevent transfusion errors.Vox Sang 1996;70(1):16-20. [ Medline ]
Williamson LM, Lowe S, Love EM, Cohen H, Soldan K, McClelland DB, et al. Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports. Br Med J 1999;319:16-9. [ full text ]